Worksheets used to record the number of hours worked and Related Supplemental Instruction hours during a registered apprenticeship on a monthly basis. If used, a copy is usually given to the program monthly.

Used by the registered apprenticeship program to setup an agreement with the apprentice.

Used to request revision of committees to include changing the title of the standards, sub-committee members, and committee members.

Used by Apprenticeship programs to submit related instruction hours to L&I Apprenticeship section. It is preferred that programs use the combined RSI/OJT reporting form. RSI Hours must be reported quarterly.

Used to report the work hours for an on-the-job training employee.

Used to allow an apprentice to transfer from a Washington State Registered apprenticeship program to another Washington State Registered program.

Used to track apprentices/trainees on-the-job training hours.

Used to document Apprentices coming from Oregon or Montana as part of the Tri-State reciprocity agreement.

Fact sheet: Assists high school students and their parents by comparing the benefits of registered apprenticeship to a traditional university or college program. Compares wages, costs, and length of study.

Brochure: Designed for tribal members, this brochure provides an overview of apprenticeship. Topics include the benefits of apprenticeship, career options, how to apply and contact information.

Brochure: Designed for construction business employers who are interested in hiring apprentices. Includes answers to common questions, how to hire apprentices, the benefits of apprenticeship, testimonials, and contact information.

Form must be filled out to request access to Apprenticeship Registration and Tracking System (ARTS).

Book: Explains the Washington State's workers' compensation program. Suggests ways to protect workers' safety and health and describes L&I programs to help employers control premium costs.

To request public records from Washington State Dept. of Labor and Industries. You can order an earlier version from the LNI warehouse until stock is exhausted.

Used by the worker to designate a person(s) as an authorized representative for the worker's claim. An authorized representative can access claim information.

Pamphlet/booklet: Designed to help employers determine if their workers are employees or independents under Washington's workers' compensation, workplace safety, wage and hour and unemployment tax laws. Includes a short "test" and helpful references.

Fact sheet: Provides an overview and resources to know your obligations when you have family members working for you. Relatives, including children, must be treated as employees with the same rights as any other paid worker in the state of Washington.

Fact sheet: Provides an overview and resources to know your obligations when you have family members working for you. Relatives, including children, must be treated as employees with the same rights as any other paid worker in the state of Washington.

Pamphlet: Concise, easy-to-read pamphlet that explains the steps to apply for a business license and what to do if you plan to employ workers. Includes how to apply to be a registered construction contractor.

DVD: Covers state business taxes and workers' compensation premiums and provides information on how to file. This 28-minute DVD can help employers plan ahead and obtain more information.

Info card: Provides information on the Employer's Intro to L&I workshop, including statewide schedule of workshops. Designed for employers and managers, the workshop covers a number of topics, including workers' compensation insurance, workplace safety, and overtime.

Booklet: Discusses the impact of the Great Recession on L&I’s programs and highlights accomplishments from 2005 to 2012.

Use to establish a factory assembled structure (FAS) deposit account. FAS deposit accounts are for businesses or other entities that are not currently licensed or registered with L&I as electrical or construction contractors but are legally required to purchase work permits from L&I. (3 pgs)

Pamphlet/booklet: Briefly explains steps to return to work quickly and minimize the economic impact of time-loss. Also provides helpful resources. Intended for injured workers.

Pamphlet/booklet: Explains the benefits of 'return to work' from the employer's perspective, describes RTW options, and provides resource and contact information.

Used by employers to teach their employees about the legal requirement to report accidents at work and who to notify if they have an accident at work. After completing the Employee Wallet Card form, the employer gives a wallet card to each employee.

Pamphlet/booklet: Provides information about the programs and services financed with workers' compensation premium dollars, along with statistics such as number of claims, demographics of claims and the most frequent types of injuries FY2012 (year ending June 30, 2012). Includes narrative about workers' compensation reforms.

Provided to workers by the self-insured businesses or their third party claims administrators to report an industrial injury or occupational disease. This form is not on the internet. If you are an injured worker, ask your employer for a copy of this form. Self-insured businesses or their third party claims administrators may order copies of this form. Cllick the "order It" button below to order paper copies or request the form in MSWord.

Used by self-insured employers or their representatives, this is legal notification to an injured worker that their claim is being closed with medical benefits only. This order is used only when neither time loss compensation nor a permanent partial disability award has been paid.

Used by medical providers when reporting initial treatment for an industrial injury or occupational disease for a self-insured claim. Medical providers treating self-insured workers, self-insured businesses, or their third party claims administrators may order copies of this form. Click the "order it" button to request paper copies. If you download the MS Word form, also download the PDF file with instructions on use of the MS Word form. The first file is an Office 2003 MSWord document with a .doc extension. The second file is an Office 2007/2010 version, with a .docx extension.

Required poster for self-insured businesses: Outlines what a worker employed by a self-insured business should do if a work-related injury or illness occurs. Note: Self-insured employers must display this poster where workers can see it. Get poster printing tips.

Pamphlet/booklet: Explains to employees of self-insured businesses their rights and responsibilities under industrial insurance law. Describes benefits and how to file a claim.

Pamphlet/booklet: Explains to employees of self-insured businesses their rights and responsibilities under industrial insurance law. Describes benefits and how to file a claim.

This form is used by self-insured injured workers who want to transfer their medical care.  Self-insured workers should complete the form and send it to their employer or their Third Party Representative.

This form is used by self-insured injured workers who want to transfer their medical care.  Self-insured workers should complete the form and send it to their employer or their Third Party Representative

Este formulario es utilizado por los trabajadores autoasegurados que desean transferir su cuidado mdico. Los trabajadores autoasegurados deben completar este formulario y enviarlo a su empleador o a su Representante de Terceros.

Used by only self-insured employers to comply with WAC 296-15-400. The form provides information and instructions to employees of self-insured employers in case of an injury or development of an occupational disease.

Used by only self-insured employers to comply with WAC 296-15-400. The form provides information and instructions to employees of self-insured employers in case of an injury or development of an occupational disease.

Used by only self-insured employers and their representatives to calculate and report injured workers’ wages and time loss compensation rates.

Used by self-insured employers and their representatives to report to L&I an injured worker's eligibility for vocational services or ability to work. This replaces F207-121-000 Employability Assessment Report (EAR).

This is a data change request form. F207-193-000 is the Self-Insurance Electronic Data Reporting System (SIEDRS) Enrollment Form

Information card: Introduces the Office of the Ombudsman for Self-Insured Injured Workers. The ombudsman is appointed by the Governor to serve as an independent advocate for the rights of injured workers of self-insured employers.

A form for Providers to submit disputes to the department regarding payment of medical provider bills

This form is a coversheet used by Self-Insurance for overpayment reimbursement fund requests.

You must fill out this form quarterly even if you had no workers. These forms are mailed out quarterly to all employers. For instructions on how to complete the Quarterly Report, please refer to F212-239-000 which is available on the internet. This file on the internet is a sample only.

Used by drywall employers as a guide to completing quarterly and supplemental reports. This includes filled out samples of F212-050-000 and F212-051-000.

Instructions for completing the Workers' Compensation Employer's Quarterly Report. A sample of the form F212-055-000 is also available on the internet.

Rack card: Information to help employers file their Workers' compensation quarterly report online. Includes filing webpages links and deadlines.

Book (loose-leaf manual): Helps contractors properly classify for industrial insurance purposes the work being performed by their employees on new wood-frame building construction projects.

Used by employers to apply for workers' compensation coverage for non-mandatory employment. Shows a list of categories of employment that are not considered mandatory to have workers' compensation.

Used by employers to request coverage of workers' compensation for non-mandatory employment. Shows a list of employment categories to choose from that are not included within the mandatory coverage of workers' compensation.

This chapter applies to employer reporting requirements for workers compensation insurance.

This chapter applies to employer classifications for workers compensation insurance.

This chapter applies to rates and experience rating rules for workers compensation insurance.

Pre-Audit Questionnaire. The fillable MSWord version is saved in the 2003 format. The EXCEL file is saved in ExCEL 2007 format. There is also a fillable PDF version.

Quick reference card: Explains the criteria to allow a corporate officer to be exempt from industrial insurance (workers' compensation) coverage. This information is part of the publication, Workers’ Compensation Record Keeping and Report Guides.

Quick reference card: Identifies the type of records employers, including construction contractors, need to keep to allow L&I to compute premiums. This information is part of the publication, Workers’ Compensation Record Keeping and Report Guides.

Quick reference card: Provides information to help determine whether a "subcontractor" working for you meets the legal requirements to be an independent contractor, or whether he/she is actually a covered worker for workers' compensation (industrial insurance) purposes. This information is part of the publication, Workers’ Compensation Record Keeping and Report Guides.

Quick reference card: Provides a list of employments excluded from workers' compensation coverage, including those eligible for optional coverage. This information is part of the publication, Workers’ Compensation Record Keeping and Report Guides.

Quick reference card: Shows employers how to figure workers' compensation premiums for different types of employees: hourly employees, salaried employees, commissioned personnel or employees paid for piecework. This information is part of the publication, Workers’ Compensation Record Keeping and Report Guides.

Quick reference card: Provides basic information about standard exception classifications, which can be separately rated from the basic business classification for determining industrial insurance (workers' compensation) premiums. This information is part of the publication, Workers’ Compensation Record Keeping and Report Guides.

Quick reference card: Reviews the requirements for members or managers of limited liability companies to be exempt from workers' compensation (industrial insurance) coverage. This information is part of the publication, Workers’ Compensation Record Keeping and Report Guides.

This is the form used by public agencies to request L&I's approval to release retainage. All contractors are to be listed on the request form. The first EXCEL document is in Office 2007 format. The second file, with the same title, is in Office 2003 format.

Form used to compute Your Workers' Compensation premiums. Page 2 has rate notice definitions. Sample only.

Fact sheet: Provides information to employers who are considering joining a Retrospective Rating (Retro) group.Contains questions and suggestions to help determine if Retro is right for a business and information regarding annual participation.

Fact sheet: Provides information to employers who are considering joining a Retrospective Rating (Retro) group and how to choose one that best fits the need of their company. Explains the process for enrollment, deadlines, group eligiblilty, assesment, distribution of funds, dues, fees, services, and exit clauses.

Pamphlet/booklet: Explains structured settlement and provides an overview of eligibility and the application and approval processes. The audience for this pamphlet is injured workers who might be eligible.

Fillable form to purchase the Workers’ Compensation Adjudicator (WCA), Claims Management (CM), and Policy Manuals (all 3 manuals on 1 CD) the costs will be added up automatically, the total amount enclosed column will be the amount you need to send as payment.

Completed by the injured worker if they are unable to work due to a workplace injury AND their employer is not paying their full wages.

Completed by the injured worker if they are unable to work due to a workplace injury AND their employer is not paying their full wages.

Used by the student and a school official each quarter to verify school enrollment.

Use by the student and a school official each quarter to verify school enrollment.

Used by a spouse or dependents of a deceased worker. The workers' fatal accident or occupational disease incurred in the course of their employment. This application is needed to determine if applicant(s) is/are entitled to a survivor benefit.

Used by dependents of a deceased worker to file a claim for benefits.

Injured worker fills this out to document possible occupational disease and to show work history.

Used by injured workers and doctors to apply to reopen an industrial injury or occupational disease claim that has been closed for longer than 60 days. 12-2009 version is in the warehouse until stock is used up, then the new 12-2012 version will be printed.

Used by injured workers and doctors to apply to reopen an industrial injury or occupational disease claim that has been closed for longer than 60 days.

Spanish version. Used by injured workers and doctors to apply to reopen an industrial injury or occupational disease claim that has been closed for longer than 60 days.

Pamphlet/booklet: Explains a worker's rights and responsibilities under industrial insurance law. Describes benefits and how to file a claim. Note: Previously titled Una gua de los trabajadores para beneficios del seguro industrial.

Used by the pensioner to notify L&I of a new mailing address. L&I must receive this form by the first day of the month so your monthly payment is received in a timely manner.

Used to provide your employment history for the past three years, including self-employment and volunteer work.

Please start with your most recent job and work backwards. Please list any gaps or interruptions in your work history.  If you were unemployed at any time, please explain why.  Did you apply for (or receive) unemployment benefits during the time period? If yes, what dates did you receive unemployment benefits?  Did you seek employment during the time period?  If no, why didn’t you seek employment?

Used by injured worker to report their employment history for the past three years and the wages at each job.

You can submit a Report of Accident (ROA) online https://secure.lni.wa.gov/home This form is not on the internet. If you are an injured worker, ask your doctor for a copy of this form. Order F242-130-999 from the warehouse to receive the instructions in Spanish to complete the form in English.

Instrucciones para el Reporte de Accidente (Lesión en el trabajo, accidente o enfermedad ocupacional). This information provides instructions in Spanish for completing the F242-130-000 Report of Accident version dated 10-2012. The F242-130-000 form is in English. Use this link to order the instructions from the warehouse. http://www.lni.wa.gov/ClaimsIns/Providers/FormPub/ROA/OrderROA.asp

Used by the widow/widower whose spouse died of a work related injury or accident. This form must be completed, signed, notarized and returned to L&I within 30 days for non interruption of your benefits.

Used by a guardian or other person having custody of the minor or disabled children or dependents of a deceased worker to declare their entitlement to receive the pension benefits for those children/dependents in their care and custody.

Used by a dependent of a worker whose death was related to an on the job injury or accident. This form must be completed, signed, notarized and returned to L&I within 30 days for non interruption of benefits.

Used by a totally permanently disabled worker. This form must be completed, signed, notarized and returned to L&I within 30 days for non interruption of benefits.

Used by pensioner to authorize L&I to deposit the pension payment to any designated financial institution.

Used by pensioner to authorize L&I to deposit the pension payment to any designated financial institution. NOTE: F242-177-999 is the Direct Deposit Letter in Spanish

Required poster: Outlines the steps a worker should take if a job-related injury or illness occurs. Also briefly describes the benefits available through Washington's workers' compensation system. Note: 'Employers who receive industrial insurance coverage from L&I must display this poster where workers can see it. English and Spanish online versions will print separately. Get poster printing tips.

Completion of this form is not a guarantee of benefits. Payment of benefits will be decided by your claim manager.

Completion of this form is not a guarantee of benefits. Payment of benefits will be decided by your claim manager.

Completion of this form is not a guarantee of benefits. Payment of benefits will be decided by your claim manager.

Completion of this form is not a guarantee of benefits. Payment of benefits will be decided by your claim manager.

Completion of this form is not a guarantee of benefits. Payment of benefits will be decided by your claim manager.

Used by medical providers to notify L&I that an occupational disease or infection has been diagnosed and that the worker has been advised that their condition may be work-related. This form can be used if the worker does not complete a Report of Accident or Occupational Disease (ROA) but should not be completed in place of an ROA.

Pamphlet/booket: Answers the most common questions about pension and survivor benefits under Washington's workers' compensation program.

Fact sheet: Explains how an injured worker can protest decisions on his/her claim and gives deadlines for taking action.

Letter of Intent for School Enrollment - Spanish CARTA DE INTENCIÓN DE REGISTRO EN UNA ESCUELA

Used by health-care providers to communicate an injured worker's status, physical capacities, inability to work (time-loss) and treatment plans. To print an APF, click on the title of the form in the box above.

Used by Spanish speaking health-care providers to communicate an injured worker's status, physical capacities, inability to work (time-loss) and treatment plans.

Utilizado por proveedores de cuidado de la salud que hablan español para indicar la condición actual del trabajador lesionado, restricciones físicas, certificación de tiempo perdido y planes de tratamiento.

Completed and signed by a State Fund injured worker to notify L&I of a change in address. All address changes must be submitted in writing and signed by the injured worker.

Used by a spouse or dependent that was chosen by the deceased worker to receive a survivor benefit. At the time the worker was determined to be totally permanently disabled he/she made a decision to leave a survivor benefit to a spouse or dependent if the worker dies.

Used by an injured worker who receives an order that states he or she is totally permanently disabled. This questionnaire must be completed in full and all necessary documents attached before his or her pension benefit options can be calculated.

Used by an injured worker who receives an order that states he or she is totally permanently disabled. This questionnaire must be completed in full and all necessary documents attached before his or her pension benefit options can be calculated.

Completed by injured workers contending eligibility for payment of back time loss benefits for a period that exceeds six months or $25,000. Injured workers requesting benefits for current time missed from work due to a work-related injury should use the F242-052-000 Worker Verification Form.

Affidavit_for_Time_Loss_Compensation_Benefits (Spanish) Declaración Firmada para Compensación de Tiempo Perdido Completed by injured workers contending eligibility for payment of back time loss benefits for a period that exceeds six months or $25,000. Injured workers requesting benefits for current time missed from work due to a work-related injury should use the F242-052-999 Worker Verification Form.

This form can only be used for services that can be authorized by the claim manager and it should not be used for Utilization Review (Qualis), Provider Hotline or requests to the Occupational Nurse Consultant.  If you are unsure of what services need to be authorized see L&I fee lookup utility.

Wallet card: Explains how to file a workers' compensation claim by telephone.

Handout: Explains to workers the basic information about L&I’s Medical Provider Network. The handout can be used with workers covered both by L&I and by self-insured employers. Applies to workers in Washington state. Includes website and phone number contact information.

Handout: Explains to workers the basic information about L&I’s Medical Provider Network. The handout can be used with workers covered both by L&I and by self-insured employers. Applies to workers in Washington state. Includes website and phone number contact information.

Employer of record can request reimbursement for wages paid to an injured worker during light duty or transitional work. After completing the form, the employer submits it, along with supporting documentation, to the Stay at Work program for review and approval. For expense reimbursements see F243-003-000.

Booklet: Explains Stay at Work, a financial incentive program that encourages Washington employers to find light-duty or transitional jobs for workers recovering from on-the-job injuries. Provides information on reimbursements, what is covered and how to apply. Detailed Q&A section included.

Pamphlet/booklet: Provides an overview Stay at Work, a financial incentive program that encourages Washington employers to find light-duty or transitional jobs for workers recovering from on-the-job injuries. Includes information on eligibility, how to apply, and where to get more information.

Stay at Work: A new program to help employers keep injured workers on the job--pays half the wage plus expenses (Programa Permanezca en el Trabajo - Un nuevo programa para ayudar a los empleadores a mantener a los trabajadores lesionados en el trabajo

Pamphlet/booklet: Provides an overview Stay at Work, a financial incentive program that encourages Washington employers to find light-duty or transitional jobs for workers recovering from on-the-job injuries. Includes information on eligibility, how to apply, and where to get more information.

Used by occupational and physical therapy providers as an optional reporting format for a Performance-based Physical Capacities Evaluation.

Used by injured worker to notify claim manager and request authorization to transfer care to a different doctor. Do it online! Use the online Transfer of Care

Used by injured worker to notify claim manager and request authorization to transfer care to a different doctor.

In order to do independent medical exams a provider must obtain a provider account number with L&I. This packet includes the application and agreement with instructions, IME Provider Exam sites form (F245-047-000) and Request for Taxpayer ID and Certification - Form W-9 (F248-036-000) (10 pages). If you have questions, please email balk235@lni.wa.gov or call 360-902-6815.

Used to apply as a interpretive service provider and to show what language(s) you hold credentials for. F248-011-000 Provider Application and Notice is added to this form.

Used when an interpreter is appointed to interpret for an injured worker during their medical visits.

The physical / occupational therapist uses this report to identify the clinical goals and return to work objectives of the injured worker.

This bill form is used by providers and injured workers to bill the department for services such as dental care; glasses; medical equipment; nursing home services; interpreter services; services workers pay for out of pocket; and other services. Information on how to bill the department can be found in the General Provider Billing Manual (F248-100-000).

Instructions in Spanish for completing the form F245-072-000 Statement for Miscellaneous Services

Bill form for prescription charges. May be used by a pharmacy to submit drug charges, or by a worker to request reimbursement for prescriptions paid out of pocket. See the General Provider Billing Manual (F248-100-000) for information on completing this form.

Bill form for use by workers to request reimbursement for authorized travel expenses.

Injured workers use this form to request reimbursement for travel expenses used to receive treatment, retraining and/or vocational services.

Providers use this to report total overpayment, partial overpayment and/or underpayment by L&I. These forms will be accepted by L&I. They may not be accepted by all Medical Bill Processors due to lack of a barcode.

Pamphlet/booklet: Answers the most common questions about independent medical exams and when and why an injured worker may be required to receive one. Includes the "IME Travel & Wage Reimbursement Request" form.

The attending doctor refers an injured worker for consultation for clinical issues, 120 day consultation and/or closing, etc.

For use by a therapist or vocational provider to request job modification for an injured worker before the injured workers is employed, possibly in a retraining program. This may involve tools and equipment that is purchased through L&I.

When prescribing opioids for chronic, noncancer pain; the attending physician must submit this form, or an equivalent form at least every 60 days. Providers are encouraged to submit after each visit.

Providers use this form to notify L&I of a change of their business address, billing address and account termination. Also has info on how to notify L&I on a tax ID (EIN) number change, tax ID address change and/or name change.

To record the training costs. For use only with plans approved after 1/1/2008.

To record the costs for transportation. For use only with plans approved after 1/1/2008.

Hearing Aid Repair Authorization Requests. If you need to purchase or replace a hearing aid, fax all of the information required by Medical Aid Rules and Fee Schedule (MARFS) including the Hearing Services Worker Information (F245-049-000) to 360-902-6252.

Includes the F248-036-000 Statewide Payee Registration and W-9 form. For providers to complete that do not want to become a Labor and Industries network provider, or for a specialty that L&I is not accepting network applications for at this time. If you are applying to be a Labor and Industries network provider, please complete application process at www.ProviderNetwork.Lni.wa.gov

To authorize L&I to accept electronically submitted bills for services provided to injured workers (2 pages).

Use this form to submit your taxpayer ID number. Note: Register now for direct deposit available at a later date.

Used by a therapy provider/clinic to request authorization for outpatient occupational or physical therapy services for L&I claims.

General billing information for those providers that bill the department.

Used by a licensed massage practitioner/clinic to request authorization for outpatient massage therapy services for L&I claims.

Used by third party attorneys to calculate distribution of proposed settlements in third party claims.

Pamphlet/booklet: Summarizes what action to take when a workplace injury is caused by a defective product or defective machine or by a person who is not a co-worker.

Used by employers to present L&I with a list of decisions they are protesting by adjustment period. The form requests all necessary elements needed for L&I to process a request for reconsideration.

Book: A publication for independent medical examiners, attending doctors and consultants, this document contains guidelines, sample reports and billing procedures for preparing and conducting impairment ratings and independent medical exams in Washington's workers' compensation system. Beginning July 1, 2012, free Category I CME credits are available for completing the self-assessment associated with this handbook. Go to www.Imes.Lni.wa.gov and click on Medical Examiners Handbook for information on the exam. L&I and the authors have no financial interest or other relationship with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in this document.

Note: The October 2012 update edition contains limited new information, including a summary of recent workers' compensation reforms. The inside pages remain the same as the 03-2005 edition. This handbook contains useful information to help providers who treat patients in the workers' compensation system. Physicians can obtain 3 hours of CE credit by completing an online self-assessment based on this handbook. L&I and the authors have no financial interest or other relationship with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in this document.

Used to obtain a vocational provider account number with L&I. This form includes a copy of F248-036-000 "Request for Taxpayer ID number and Certification". (12 pages) CURRENT EXISTING VOCATIONAL PROVIDER FIRMS THAT ARE ALREADY REGISTERED WITH L&I USE THIS FORM AND W-9.

To change an individual's (service provider's) name, add or delete referral categories, update certifications, leaving a firm, intern supervisor changes, and/or adding or deleting a branch for referrals.

Used by employer of record to prepare a written job description for a light-duty job, transitional, modified duty job, or alternative job when an injured worker is unable to work due to an industrial injury or occupational disease. The form includes a description of the job tasks, machinery, tools, equipment and personal protective equipment used, and the physical demands of the job. After completing the employer's job description form, the employer gives it to the injured worker's doctor for review and approval.

Fact sheet: Answers questions about the home modification benefit in Washington State's workers' compensation program, who qualifies, what L&I can pay, and where to get more information.

Fact sheet: Answers questions about the home modification benefit in Washington State's workers' compensation program and the bid process for contractors interested in this work.

Fact sheet: Reviews the options that an injured worker with low-back pain should consider in determining the best treatment choice.

Used by rehabilitation providers to document in a vocational assessment that a worker needs further services.

Complete this application and the StateWide Payee W-9 if you are applying for a firm Provider Number with L&I.

Use this form to request opioid coverage beyond 12 weeks from the date of injury or surgery, or every 90 dats for chronic opioid therapy.

Answers questions persons with a terminal illness may ask about benefits from L&I.

Use this treatment agreement when starting chronic opioid therapy. It should be renewed yearly or when there is a new prescriber.

Stand-alone document that can be used with all Ability to Work Assessment outcomes.

Use this form to request opioid coverage between 6 weeks to 12 weeks from the date of injury or surgery.

Used by employees who believe they have been discriminated against by their employer may use this form to file a complaint.

History of Hearing Loss and Continuation Sheet - Spanish - HISTORIA DE TRABAJO PÉRDIDA DE AUDICIÓN

Used by injured worker who has filed an occupational hearing loss claim to provide more specific information regarding how the hearing loss occurred. This is requested by the Claim Manager and sent to the Injured Worker.

Fact sheet: Tells construction contactors how to protect themselves from liability for their subcontractor's unpaid workers' compensation premiums.

For use internally by L&I Vocational Service Specialists (VSSs) to determine if all required components are included in the submitted assessment.  Can be used by VRCs as a tool.  DO NOT SUBMIT TO L&I.

This document provides the facts necessary to make an informed decision regarding vocational retraining benefits and explains the responsibilities you and your vocational counselor (VRC) have. For OJT retraining plans, please refer to form F280-029-000.

This document provides the facts necessary to make an informed decision regarding vocational retraining benefits and explains the responsibilities you and your vocational counselor (VRC) have.

Booklet: Explains the basics of the assessment phase of vocational services to injured workers. L&I sends this booklet to injured workers when they are referred for assessment services.

Booklet: Explains the basics of the plan development phase of vocational services to injured workers. L&I sends this booklet to injured workers when they are referred for plan development services. The assigned vocational rehabilitation counselor is required to review this booklet with the worker at their initial face-to-face meeting.

Pamphlet/booklet: Describes the Preferred Worker Program and the benefits employers receive when hiring a preferred workers. Iin general, these are workers whose work-related injury or occupational disease prevents them from returning to their old job.

Pamphlet/booklet: Describes the Preferred Worker Program and the benefits employers receive when hiring a preferred workers. In general, these are workers whose work-related injury or occupational disease prevents them from returning to their old job.

Used by vocational providers to apply for preferred worker status on behalf of an industrially injured worker.

State fund workers who have selected Option 2 and closed their claim can use this form to apply for access to their Option 2 training funds. To seek reimbursement, use form F245-030-000 Statement for Retraining and Job Modification Services.

State fund workers who have selected Option 2 and closed their claim can use this form to apply for access to their Option 2 training funds. To seek reimbursement, use form F245-030-000 Statement for Retraining and Job Modification Services.

OJT Accountability Agreement in Spanish

Fact sheet: Includes information regarding the benefits of Preferred Worker certification, answers to questions frequently asked by workers, phone and website contacts.

Fact sheet: Includes information regarding the benefits of Perferred Worker certification, answers to questions frequently asked by workers, phone and website contacts.

Book: Provides employers a checklist on the requirements of the chemical hazard communication rule. Contains an extensive question-and-answer section and information on starting an employee-training program.

Pamphlet/booklet: Reviews the symptoms and risk factors for carpal tunnel syndrome and several other musculoskeletal disorders that affect the shoulder, arm and elbow. Discusses prevention approaches and where to get more information.

Full-color photographs of poison oak in different seasons help workers recognize and avoid the plant when working outdoors. Note: Poster will split over two pages if printed on 8.5" X 11" paper. Get poster printing tips.

Employers must complete this form for the employee for each periodic/follow-up test and provide a copy to the health care provider.

Filled out by the provider. This form gives the recommendations by the provider of what needs to be done based on the test results on the employee.

Safety Standards for Electrical Workers, 296-45 WAC, consist of the requirements for safeguarding employees against electrical hazards in their workplace; requirements for electric equipment and wiring in locations classified as hazardous.

Construction work shall mean and include all or any part of excavation, construction, erection, alteration, repair, demolition, and dismantling, of buildings and other structures.

The rules included in this chapter apply to any and all waterfront operations for longshore, stevedore and waterfront  related operations, cargo handling, and related terminal operations and equipment under the jurisdiction of the  Department of  Labor and  Industries.

This manual contains basic safety and health rules that affect all employers and should cover almost all commercial diving operations. This manual also covers search and rescue and other public safety diving operations.

The rules in this chapter are designed to protect the safety and health of employees by creating a healthy work environment by establishing requirements to control safety hazards in the workplace.

The Core rules contains basic safety and health rules that affect all employers and should cover almost everything small, nonmanufacturing employers need for a safe and healthful workplace.

Pathogenic microorganisms that are present in human blood and can cause disease in humans.

CD: Contains workplace safety and health rules for Washington State and links to policies and related laws. Also contains guides covering accident prevention programs (APP) and personal protective equipment (PPE). Note: Order CD or view rules online.

Safety Standards - WAC 296-817, Hearing Loss Prevention (Noise)

An apparatus worn over the mouth and nose or the entire face to prevent the inhalation of dust, smoke, or other noxious substances. Respirator is a type of personal protective equipment designed to protect the wearer from airborne contaminants, oxygen deficiency, or both.

This chapter applies to powered industrial trucks, electric motors or internal combustion engines, fork trucks, forklifts, tractors, platform lift trucks, motorized hand trucks and other specialized industrial trucks.

This chapter applies to portable and fixed ladders, including job-made wooden ladders, ladder safety, the proper construction, use, placement, and care in handling ladders.

Administrative Rules and the DOSH Administrative Manual affords employers the right to administrative and judicial review of alleged violations, initial penalties and abatement periods.

Booklet: Provides an overview of revised fall protection rules and requirements for construction activities effective April 1, 2013.

Chapter 296-901 WAC, GHS is the Globally Harmonized System of Classification and Labeling of Chemicals. The GHS is a system for standardizing and harmonizing the classification and labeling of chemicals.

Use this form to file a complaint when you feel you've been discriminated against or discharged for reporting a workplace safety hazard.

Si Usted piensa que ha sido discriminado o despedido por reportar los peligros existentes en su lugar de trabajo, utilice este formulario para presentar una queja.

Mobile Cranes/Derricks Worksheet for Construction Industry

Bulk Cargo Spouts, Suckers, and Similar Equipment for Maritime Operations

Required poster: Describes important parts of the Washington Industrial Safety and Health Act (WISHA), which provides for job safety and health of Washington employees. Note: Employers in Washington State must display this poster where workers can see it. When ordering the printed version, you will receive one 22" X 17" poster that includes both languages. Get poster printing tips.

Pamphlet/booklet: Provides an overview of the Washington Industrial Safety and Health Act (WISHA), worker and employer rights and responsibilities, enforcement of WISHA rules, and consultation and education services L&I provides. Previously titled A Guide to WISHA

Pamphlet/booklet: Provides an overview of the Washington Industrial Safety and Health Act (WISHA), worker and employer rights and responsibilities, enforcement of WISHA rules, and consultation and education services L&I provides. Previously titled A Guide to WISHA

Use this two part form for employers to record work locations and emergency rescue info and for holding safety meetings for each new jobsite

Use this form to document the minutes of your safety meetings.

Fact sheet: Provides 10 tips for safer lifting. Contains illustrations.

For use by consultants to evaluate employers' accident prevention programs. Use this form for large employers (more than 50 employees).

Use this form to record the minutes from your safety meetings - these records must be retained for one year from the date of each meeting

Use this form to record the minutes from your safety meetings - these records must be retained for one year from the date of each meeting

The employer uses this checklist to determine the person they have designated as a competent person is competent within the description and intent of the fall restraint and fall arrest stanard.

This booklet defines the work plan requirements you must meet for fall protection.

This form is used to analyze accident prevention programs for your business. This is only available online.

Poster: Employees have the right to report concerns about safety and health in their workplace. This poster describes "protected activities" under the Washington Industrial Safety and Health Act (WISHA) and explains what an employee should do if he/she has been punished or fired for exercising these rights. Get poster printing tips.

Pamphlet/booklet: This advisory pocket guide reviews 14 workplace risk factors that can lead to soft tissue injuries such as back strain, tendinitis and carpal tunnel syndrome. Suggests ways to identify the risk factors. Lists helpful resources from L&I.

Fact sheet: Provides answers to the most-often asked questions about forklift training. Includes a checklist that employer may use to document that employees have been trained and/or evaluated in the required topics.

Pamphlet/booklet: Describes the benefits of free employer consultations offered by L&I's Division of Occupational Safety and Health (DOSH). These services include on-site safety and/or industrial hygiene consultations, ergonomics assistance and risk management advice.

Pamphlet/booklet: Describes the benefits of free employer consultations offered by L&I's Division of Occupational Safety and Health (DOSH). These services include on-site safety and/or industrial hygiene consultations, ergonomics assistance and risk management advice.

Pamphlet/booklet: Uses a story format with dialogue and photographs to explain the hazards of cholinesterase-inhibiting pesticides, the state's monitoring program and the importance of using proper safety equipment when working with pesticides.

Identifies the effects of heat exhaustion and heat stroke on the body and what to do if you observe symptoms. Reviews prevention steps. PDF file is set up for two copies to print at one time.

Safety and Health Program Assessment Worksheet

Booklet: Gives information needed to prevent nail gun injuries for construction employers.

Pamphlet: Provides information to employers interested in a free ergonomics consultation for their business. Explains the importance of workplace ergonomics and how L&I can help to assess injury-causing tasks, and help develop an ergonomics program.

Pamphlet: Summarizes the safety rules for rollover protective structures (ROPS) and seatbelts on tractors. Also lists exemptions and provides other information about safe operation of tractors.

Fact sheet: Explains how an employer requests a "stay of abatement date." Effective July 1, 2012, an employer must fix a hazard cited in a workplace inspection during appeal unless he or she has requested and been granted a stay of abatement date.

Calendar: Features real Washington State businesses and employees handling typical workplace hazards with an emphasis on safety and health improvements over the past decades. It includes suggested weekly safety and health tips for different industries, including healthcare, logging, law enforcement, food processing and more.

Poster for tire and rim servicing. To be displayed with F417-237-000-B Demounting and Mounting Procedures for Tube-type Truck and Bus Tires and F417-237-000-C Multi-piece Rim Matching Chart. This poster must be printed at least 2'x3' in size.

Poster for tire and rim servicing. To be displayed with F417-237-000-A Demounting and Mounting Procedures for Tubeless Truck and Bus Tires and F417-237-000-C Multi-piece Rim Matching Chart. This poster must be printed at least 2'x3' in size.

Poster for tire and rim servicing. To be displayed with  F417-237-000-A Demounting and Mounting Procedures for Tubeless Truck and Bus Tires and F417-237-000-B Demounting and Mounting Procedures for Tube-type Truck and Bus Tires. This poster must be printed at least 2'x3' in size.

Brochure: Provides information to loved ones of workers who died from a job-related injury or illness, including how to apply for survivor benefits. Explains the L&I fatality investigation and how family members can stay informed of the investigation's status.

Brochure: Provides information to loved ones of workers who died from a job-related injury or illness, including how to apply for survivor benefits. Explains the L&I fatality investigation and how family members can stay informed of the investigation's status.

Pocket guide: Provides links to online information, including safety and health consultations, how to develop a safety program, reporting hazards and injuries, other safety training, and information for teen workers.

Fact sheet: Provides information about changes to OSHA'S Federal Hazard Communication Standard, which triggers the need for changes to Washington State's standard. Rulemaking is under way in 2013. The changes are intended to improve comprehension of hazard information found in product labels to more effectively prevent injuries, illnesses and fatalities.

Fact sheet: Provides information about changes to OSHA'S Federal Hazard Communication Standard, which triggers the need for changes to Washington State's standard. Rulemaking is under way in 2013. The changes are intended to improve comprehension of hazard information found in product labels to more effectively prevent injuries, illnesses and fatalities.

Booklet: Provides a summary of occupational injury and illness data, including safety and health violations cited, by the top 25 hazardous industries for the five-year period 2006 to 2010.

Brochure: Employees have the right to report concerns about safety and health in their workplace. This brochure describes "protected activities" under the Washington Industrial Safety and Health Act (WISHA) and explains what an employee should do if he/she has been punished or fired for exercising these rights.

Q&A Factsheet: Answers to questions crane or derrik operators/owners might have regarding vehicle/operator certification and training required for cranes and derriks based on possible construction site scenerios.

Employees use this complaint form to report work place conditions which jeopardize workers safety and health.

Construction Checklist - Safety

Construction Checklist - Safety - Spanish - Lista de verificación de seguridad en la construcción

To request a duplicate or replacement of your Washington state electrical license or certificate.

Electrical Safety Standards,Administration, and Installation WAC 296-46B

This affidavit is used to record the hours of a trainee's electrical experience with direct supervision under a Washington certified journeyman, master or specialty electrician.

To renew your electrical certificate. Fee varies depending on renewal type.

Used to get approval of a course as an electrical continuing education class. This application must be received by L&I at least 30 days before the course is offered.

Use this form to apply for the master electrician exam.

This application is used to apply for a valid electrical permit from L&I. 4 pages.

This application is used to apply for a valid electrical permit. 5 pages.

Covers 03A, 06B, 07A, 07B, 07C, 07D, 07E, and 10 specialty licenses.

Used by an Engineer to apply for accreditation by L&I to approve unlisted equipment.

Fact Sheet: Explains Class B label electrical work, scope and limitations, and provides general instructions for using Class B labels.

Fact Sheet: Provides information for requesting electrical inspections, including telephone numbers and locations of L&I offices that handle electrical inspections.

Class B Book Refund Request Form for the purpose of requesting a refund of Class B Books purchased prior to March 1, 2013.

To assign or unassign your status as an administrator or master.

Checklist which reflects the most common violations found by Field Inspectors. This checklist should be gone through prior to calling for an inspection of Low Pressure Steam Boilers

Checklist which reflects the most common violations found by Field Inspectors. This checklist should be gone through prior to calling for an inspection of High Pressure Boilers

Used for installation application for elevators (new, renewals, and alterations)

Used by the installer to notify L&I that a conveyance is proposed for installation in a buildiing.

A form to request a refund for an electrical work permit, elevator permit, or factory-assembled structure alteration permit.

Checklist for homeowners on how to upgrade their pre-HUD homes to approach the HUD standards in the area of fire safety.

Checklist for homeowners on how to upgrade their pre-HUD homes to approach the HUD standards in the area of fire safety.

This checklist is designed to be generic in content and may not include all requirements for your particular installation.

Used in requesting a plan approval for Conversion Vendor or Medical Unit factory-assembled structures.

Used by a homeowner or contactor to request a field inspection for an alteration to a manufactured or mobile home.

Pre-Inspection Checklist to assist vendor owners, manufacturers, and others on what they need to know to get their vendor/medical unit approved by Labor and Industries.

The purpose of the manufactured home roof affidavit is to provide timely inspections and communications between the contractor and/or owner and FAS inspectors and field staff.

A structural inspection request questionnaire will not be required when a roof change out occurs if no structural changes are made in the roof sub-surface and roof cavity. Example: Repairing or replacing the roof trusses, rafters, ridge beam and the replacement of not more than (4) 4’x 8’ of roof sheathing.

You must have a contractor license number or have completed an application for a miscellaneous account to use this form.

Listing of Connected Loads and the Demand Loads. Used for all appliances that are fastened in place, permanently connected on specific circuit. Single Phase Panel Schedule and Three Phase Panel Scheule inlcude. Sample diagram included.

Used to apply for an official insignia for conversion vendor or medical unit factory-assembled structures. See sample form for instructions about how to fill out the form correctly.

This is the form you would complete to register as a construction conractor.

This form is used for the surety bond for construction contractors.

Contractors may use this form to request an Assignment of Account in lieu of a surety bond. The amount of the surety bond would need to be placed into an account at a WA State Bank.

This is a waiver of lien by a contractor or a subcontractor or supplier.

This disclosure statement is given to the consumer (customer) from the contractor showing they are registered in the state of Washington. The consumer (customer) signs this form as acknowledgement of receipt.

Used by a home owner to file a complaint against a contractor.

Pamphlet/booklet: Explains the steps to register as a construction contractor in Washington State.

General requirements that a lien claimant of a private construction project (not a commercial) must meet. This is intended show the general requirements for most lien claimants.

This is a fillable version of the Registered Contractor Card

Used by employers with no employees or worker hours to report but need an open account for contract bidding process.

Pamphlet/booklet: Provides a checklist for consumers considering hiring a general or specialty construction contractor, reviews the permitting process, and suggests ways to avoid lien problems. Washington State law requires contractors to register with L&I.

Fact sheet: Provides a checklist for consumers considering hiring a general or specialty construction contractor, reviews the permitting process, and suggests ways to avoid lien problems. Washington State law requires construction contractors to register with L&I.

This form may be faxed to the Contractor Registration office in Tumwater.

Contractor Registration Officers/Members Addendum

Checklist: Provides information to help screen potential contractors for home construction or repair/remodel projects. Presented in an organized, step-by-step format.

Used to apply for an upgrade from Specialty Contractor to a General (01) Contractor.

Application and instructions for a Washington State electrician's certificate examination.

This the application for an Electrical Training Certificate or the renewal of. (This does NOT make you a registered apprentice).

The 2013 Plumber Examination Dates and Locations. A printed version is also available from the L&I Warehouse.

For legal guardians and school officials to approve the hours and work activities for a minor employee to work according to terms listed by the employer. The Special Variance allows additional hours of work for 16- and 17-year-olds and is described on the form. All parties must sign to approve the hours of work for a minor regardless of the number of hours listed. This is NOT a work permit. Employers must obtain a minor work permit endorsement on their Master Business License where they employ workers under 18.

Pamphlet/booklet: Answers questions employers, parents and teens may have about employing teen workers (ages 14-17). Explains non-agriculture work rules, including the necessary permits, hours and work conditions. Provides links to other resources.

Employment wages and conditions agreement with Farm Labor Contractors and Workers

Covers exemptions to Washington state minimum wage law.

This is a copy of the law that pretains to the payment of wages to an employee when they stop working for an employer. The wages due to the employee for the pay period worked prior to leaving.

There are instructions in one PDF file, and a blank form that may be printed in the other PDF. The word document is saved in Microsoft 2003 format and is a fillable word form.

Required poster: Reviews workers' rights under Washington's wage-and-hour laws. Topics include minimum wage, overtime, meal and rest breaks, pay periods, deductions, and employment of teens under age 18. Also reviews family leave provisions under federal and state law, and leave for spouses of deploying military personnel and victims of domestic violence. Note: Employers in both agricultural and non-agricultural industries in Washington State must display this poster where workers can see it. Get poster printing tips.

Nonagricultural Employment of Minors Chapter 296-125 WAC

Agricultural Employment Standards - Chapter 296-131 WAC (Spanish) Estándares de Trabajo Agrícola

Fact Sheet: Explains how to get a farm labor contractor license in order to operate legally as a farm labor contractor in Washington State.

Pamphlet/booklet: Answers many questions employers and minor workers have about employing minors. Covers agriculture work rules, including the necessary permits, hours and work conditions for workers 12-17 years of age.

Form to gain Internal Revenue Service Tax Compliance Certification for registered Farm Labor Contractors. Now includes IRS form 8821 Tax Information Authorization.

Used to file a complaint against a Farm Labor Contractor, landowner, employer, or other where a possible infraction is concerned.

Farm Labor Contractor's Checklist to ensure compliance.

Used by agricultural employers to assist them in determining if they are following the state Agricultural Employment Standards and the Minimum Wage Act for their employees.

Checklist used for the filing of Prevailing Wage Complaints by "Interested parties" ONLY.

Flier: Provides important information about hiring teens, including extra safety precautions, as well as legal requirements begarding minor work endorsement, hours and prohibited duties. Provides telephone, e-mail and Web contacts for more information.

For leave from work complaints: Download and complete a Protected Leave Complaint form (F700-144-000)

Para quejas de ausencia del trabajo: Descargue y complete un formulario de Queja sobre permiso de ausencia protegida (F700-144-999)

Ask L&I to conduct an investigation into a prevailing wage-related issue that affects one or more employees.

This is the Worker Rights Complaint Form. Both the 12-2011 and 10-2010 versions are valid.

Worker Rights Complaint Form. Both the 10-2010 and 12-2011 versions are valid.

Plain Talk Summary of Prevailing Wage Laws: Understand Your Responsibilities and Rights When Performing Public Work - Spanish (Resumen de las Leyes de Salario Prevaleciente en Lenguaje Sencillo Entienda sus Responsabilidades y Derechos al Hac

8.5" X 11" sheets: Provides a summary of prevailing wage laws and rules in Spanish. This publication is only available in Spanish. For similar information in English, read the Washington State Prevailing Wage Law booklet.

Fact sheet: Explains how employers could be liable for unpaid workers' compensation premiums, unpaid wages, damages and civil penalties when hiring a farm labor contractor. Outlines ways to protect against potential liability.

Fact sheet: Explains permitted and prohibited work activities for youth ages 14 to 17 in food service. Includes rules for driving, student-learner exemptions and work hours.

This form is for summer employment of minors, only, and is for parents or legal guardians to approve the hours and work activities for a minor employee to work according to terms listed by the employer.  All parties must sign to approve the work schedule and duties for a minor prior to permitting them to work.  This is NOT a work permit.  Employers must obtain a minor work permit endorsement on their Business License where they employ workers under 18.

Pamphlet/booklet: Answers questions about Washington State's Crime Victims Compensation Program, who may be eligible for benefits and how to apply.

Benefits are limited to $50,000 per claim. if your claim has met or exceeded this cap, your reopening application will be denied and we will be unable to pay any further benefits. Used by victims of crime and medical or mental health providers to request a claim be reopened.

Benefits are limited to $50,000 per claim. if your claim has met or exceeded this cap, your reopening application will be denied and we will be unable to pay any further benefits. Used by victims of crime and medical or mental health providers to request a claim be reopened.

Used by victims of a crime in Washington State to receive benefits for time lost from work, loss of financial support, medical or mental health treatment. The Spanish version of the instructions are online as F800-042-999.

Instructions in Spanish to complete the English form F800-042-000 Application for Crime Victim benefits. The form is used by victims of a crime in Washington State to receive benefits for time lost from work, loss of financial support, medical or mental health treatment. This 12-10 version is internet only.

Master Level Counselor Provider Account Application for Crime Victims

Used by immediate family members of homicide victims to request mental health counseling.

Used by a provider assisting victims of crime to obtain a taxpayer ID number. Note: Register now for direct deposit available January 2013.

Used by the provider or supplier for reimbursement of the following services - dental, glasses, home health, nursing home serivces, medical equipment, prosthetics-orthotics, transportation, vocational, retraining and other.

Provides information health-care providers need to bill the Crime Victims Compensation Program for medical services.

Manual: This manual is for providers who bill the Crime Victims Compensation Program for mental health services for crime victims.

Crime Victim Worker Verification - Spanish - Formulario de Verificación de Empleo

This is a test

Poster: Displays proper hand signals for directing crawler, locomotive and truck crane operators. Please order from L&I or print on 11" X 17" paper.

Poster: Trench safety information for employers. Features tips to prevent cave-ins, and proper inspection proceedures. Get poster printing tips.

Tips on handling cash and how to have a safer restaurant or retail environment. Get poster printing tips.

Sticker: 8.5 inches X 3.5 inches

Sticker size 4"x3"

Large words: Report All Injuries Promptly. Get poster printing tips.

Sticker size 5"x6"

Picture of workers on a high rise. Get poster printing tips.

Large words: Peligro - Área en Construcción -  Solamente Personas Authorizadas. Get poster printing tips.

Large lettering: PELIGRO